The fine line between harm reduction and harm production - development of a clinical policy on femoral (groin) injecting

The femoral region ('groin') appears to be increasingly commonly used by injecting drug users in the UK. With the advent of Britain's first supervised prescribed injectable opioid treatment clinic, unprecedented decisions and judgements were required about the safe supervision of this practice, or whether to permit this behaviour on site at all. This paper reports the reasons for, and outcome of, development of a clinical policy on injecting into the deep femoral vein (groin injecting)

Femoral sulcus angle and increased patella facet cartilage volume in an osteoarthritic population

Objective
The patellofemoral joint is an example of an incongruent articulation commonly affected by osteoarthritis (OA). The relationship between femoral sulcus angle and the development and progression of patellofemoral OA is unclear. The aim of this study was to examine the relationship between the femoral sulcus angle at baseline and patella cartilage volume at baseline and at 2-year follow-up among community based adults with established knee OA.

Methods
One hundred subjects had magnetic resonance imaging of their symptomatic knee at baseline and at 2-year follow-up. From these images, patella cartilage volume was determined. Radiographic skyline views of the patellofemoral joint were taken at baseline to measure the femoral sulcus angle.

Results
For every 1° increase in the femoral sulcus angle (i.e., as the sulcus angle became more shallow) there was an associated 9.1 mm3 (95% CI 3.1, 15.0) increase in medial patella cartilage volume at baseline (P = 0.003). There was a similar trend that approached statistical significance between the femoral sulcus angle and the lateral patella facet cartilage volume at baseline (P = 0.09). There was no association between the femoral sulcus angle at baseline and the change in patella cartilage volume over 2 years in either patellofemoral compartment.

Conclusion
These results infer that the femoral sulcus angle is a cross-sectional determinant of the amount of patella cartilage, but is not a major determinant of the annual change of patella cartilage volume among people with knee OA. These data suggest that a shallower sulcus in the context of established OA may be an advantageous anatomical variant. Further longitudinal studies are required to determine the role of the femoral sulcus angle in OA.

Natural fiber reinforced composites for femoral component of total hip arthroplasty

This paper describes a theoretical approach to compare two types of fiber reinforced composite materials for femoral component of hip implants. The natural fiber reinforced composite implant is compared with carbon fiber reinforced composite and the results are evaluated against the control solution of a metallic implant made of titanium alloy. With identical geometry and loading condition, the composite implants assumed lower stresses, thus induced more loads to the bone and consequently reduced the risk of stress shielding, whilst the natural fiber reinforced composite showed promising result compared with carbon fibers. However, natural fibers, as well as carbon fibers, lack the power to improve interface debonding due to excessive loads in interface. Nevertheless, natural fiber reinforced composite could be an appropriate alternative given its capability of tailoring and achieving the optimal fiber orientation and robust design.

Contextual influences on femoral injecting behaviour in the UK Randomised Injectable Opiate Treatment Trial

Femoral injecting amongst participants of the Randomised Injectable Opiate Treatment Trial (RIOTT) has created a number of procedural, ethical and medical dilemmas for staff, clients and researchers. This study investigated the effect on femoral injecting behaviour of a drug consumption room (DCR) in the context of the RIOTT currently being conducted at the Maudsley Hospital, South London. It uses in-depth qualitative interviews with 10 RIOTT clients to investigate the effects of this environmental intervention on the injecting behaviour of individuals who injected femorally upon treatment entry. Interviewees were selected on the basis of membership in one of four groups: 1) never injected femorally, 2) injected femorally prior to trial and have ceased completely, 3) injected femorally prior to trial and have ceased within the DCR, and 4) have continued to inject femorally the inside and outside clinical settings. The paper uses case studies and clinical protocols to interpret changes in behaviour in injecting behaviour in regards to the goals of treatment. Preliminary results indicate that there are major advantages and disadvantages associated with femoral injecting. The most commonly reported reason for commencing femoral injecting was a lack of other viable veins and interviewee narratives illustrate how this issue use addressed within the context of the DCR. Within this setting, the paper explores the boundaries of harm reduction in the context of a traditional 'risk boundary' within the 'ideal' risk environment. Other issues explored include: gender differences in femoral injecting episodes, femoral injecting as a risk boundary and the importance of time pressures as a major predictor of choosing to inject femorally.

Pain relief for the removal of femoral sheath in interventional cardiology adult patients (Review)

Pain relief for removal of femoral sheath after cardiac procedures
Procedures for the non-surgical management of coronary heart disease include balloon angioplasty and intracoronary stenting. At the start of each procedure an introducer sheath is inserted through the skin (percutaneously) into an artery, frequently a femoral artery in the groin. This allows the different catheters used for the procedure to be exchanged easily without causing trauma to the skin. At the end of the procedure the sheath is removed and, if the puncture site isn't "sealed" using a device closure, firm pressure is required over the site for 30 minutes or more to control any bleeding and reduce vascular complications. Removing the sheath and the firm pressure required to control bleeding can cause pain, although this is generally mild. Some centres routinely give pain relief before removal such as intravenous morphine, or an injection of a local anaesthetic in the soft tissue around the sheath (called a subcutaneous injection). Adequate pain control during sheath removal is also associated with a reduced incidence of a vasovagal reaction, a potentially serious complication involving a sudden drop of blood pressure and a slowed heart rate. Four studies were reviewed in total. Three trials involving 498 participants compared subcutaneous lignocaine, a short acting local anaesthetic, with a control group (participants received either no pain relief or an inactive substance known as a placebo). Two trials involving 399 people compared intravenous opioids (fentanyl or morphine) and an anxiolytic (midazolam) with a control group. One trial involving 60 people compared subcutaneous levobupivacaine, a long acting local anaesthetic, with a control group. Intravenous pain regimens and subcutaneous levobupivacaine appear to reduce the pain experienced during femoral sheath removal. However, the size of the reduction was small. A significant reduction in pain was not experienced by participants who received subcutaneous lignocaine or who were in the control group. There was insufficient data to determine a correlation between pain relief administration and either adverse events or complications. Some patients may benefit from routine pain relief using levobupivacaine or intravenous pain regimens. Identifying who may potentially benefit from pain relief requires clinical judgement and consideration of patient preference. The mild level of pain generally experienced during this procedure should not influence the decision as some people can experience moderate levels of pain.

Femoral neck geometry and hip fracture risk : the Geelong Osteoporosis Study

To determine the relationship between femoral neck geometry and the risk of hip fracture in post-menopausal Caucasian women, we conducted a retrospective study comparing the femoral neck dimensions of 62 hip fracture cases to those of 608 randomly selected controls. Measurements were made from dual-energy X-ray absorptiometry scans (Lunar DPX-L), using the manufacturers ruler function, and included: hip axis length (HAL), femoral neck axis length (FNAL), femoral neck width (FNW), femoral shaft width (FSW), medial femoral shaft cortical thickness (FSCT_med), and lateral femoral shaft cortical thickness (FSCT_lat). The fracture group was older (median age 78.3 years vs 73.8 years), lighter (median weight 59.9 kg vs 64.5 kg), and, after adjustment for age, taller (mean height 158.7±0.8 cm vs 156.7±0.2 cm) than the controls. Furthermore, bone mineral density was lower in this group (0.682±0.016 g/cm² vs 0.791±0.006 g/cm²). After adjustment for age, bone mineral content (BMC) or height, hip fracture patients had greater FNW (up to 6.6%) and FSW (up to 6.3%) than did the controls. Each standard deviation increase in FNW and FSW was associated with a 1.7-fold (95% CI 1.3–2.3) and a 2.4-fold (95% CI 1.8–3.2) increase in the fracture risk, respectively. BMC-adjusted FNAL was greater in the fracture group (+2.1%) than in the controls, while the age-adjusted FSCT_med was reduced (–7.2%). There was a trend towards longer HAL (up to 2.1%) after adjustment for age or BMC, and thinner age-adjusted FSCT_lat (–1.7%) in fracture patients that did not reach statistical significance. In multivariate analysis, the risk of hip fracture was predicted by the combination of age, FNW, FSW, BMC and FSCT_med. HAL was not analyzed because of the small number of HAL measurements among fracture cases. We conclude that post-menopausal women with hip fractures have wider femoral necks and shafts, thinner femoral cortices and longer femoral neck axis lengths than do women with no fractures. Alteration in hip geometry is associated with the risk of hip fracture.

Femoral neck dimensions are unlikely to be associated with age at menarche

Hip axis length (HAL) has been reported as an independent risk factor for hip fracture. Later puberty may increase bone size because of delayed epiphyseal fusion. We sought to identify associations between bone size at the proximal femur with age at menarche and other indices of growth such as stature. Femoral neck dimensions were measured from dual-energy X-ray absorptiometry scans of the proximal femur in a random sample of 203 premenopausal Caucasian women (age 20–30 years). There were no associations between age at menarche and HAL, femoral axis length (FAL) or femoral neck width (FNW). Age at menarche was associated with height (r= 0.2, p= 0.02). Variations in HAL, FAL and FNW do not appear to be related to age at menarche.

Glutamine repeat variants in human RUNX2 associated with decreased femoral neck BMD, broadband ultrasound attenuation and target gene transactivation

RUNX2 is an essential transcription factor required for skeletal development and cartilage formation. Haploinsufficiency of RUNX2 leads to cleidocranial displaysia (CCD) a skeletal disorder characterised by gross dysgenesis of bones particularly those derived from intramembranous bone formation. A notable feature of the RUNX2 protein is the polyglutamine and polyalanine (23Q/17A) domain coded by a repeat sequence. Since none of the known mutations causing CCD characterised to date map in the glutamine repeat region, we hypothesised that Q-repeat mutations may be related to a more subtle bone phenotype. We screened subjects derived from four normal populations for Q-repeat variants. A total of 22 subjects were identified who were heterozygous for a wild type allele and a Q-repeat variant allele: (15Q, 16Q, 18Q and 30Q). Although not every subject had data for all measures, Q-repeat variants had a significant deficit in BMD with an average decrease of 0.7SD measured over 12 BMD-related parameters (p = 0.005). Femoral neck BMD was measured in all subjects (−0.6SD, p = 0.0007). The transactivation function of RUNX2 was determined for 16Q and 30Q alleles using a reporter gene assay. 16Q and 30Q alleles displayed significantly lower transactivation function compared to wild type (23Q). Our analysis has identified novel Q-repeat mutations that occur at a collective frequency of about 0.4%. These mutations significantly alter BMD and display impaired transactivation function, introducing a new class of functionally relevant RUNX2 mutants.

Mid-femoral and mid-tibial muscle cross-sectional area as predictors of tibial bone strength in middle-aged and older men

While it is widely acknowledged that bones adapt to the site-specific prevalent loading environment, reasonable ways to estimate skeletal loads are not necessarily available. For long bone shafts, muscles acting to bend the bone may provide a more appropriate surrogate of the loading than muscles expected to cause compressive loads. Thus, the aim of this study was to investigate whether mid-thigh muscle cross-sectional area (CSA) was a better predictor of tibial mid-shaft bone strength than mid-tibia muscle CSA in middle aged and older men. 181 Caucasian men aged 50–79 years (mean±SD; 61±7 years) participated in this study. Mid-femoral and mid-tibial bone traits cortical area , density weighted polar moment of area and muscle CSA [cm²] were assessed with computed tomography. Tibial bone traits were positively associated with both the mid-femur (r=0.44 to 0.46, P<0.001) and the mid-tibia muscle CSA (r=0.35 to 0.37, P<0.001). Multivariate regression analysis, adjusting for age, weight, physical activity and femoral length, indicated that mid-femur muscle CSA predicted tibial mid-shaft bone strength indices better thn mid-tibia muscle CSA. In conclusion, the association between a given skeletal site and functionally adjacent muscles may provide a meaningful probe of the site-specific effect of loading on bone.

The effect of known cardiovascular risk factors on carotid-femoral pulse wave velocity in school-aged children: a population based twin study

Childhood cardiovascular risk factors affect vascular function long before overt cardiovascular disease. Twin studies provide a unique opportunity to examine the influence of shared genetic and environmental influences on childhood cardiovascular function. We examined the relationship between birth parameters, markers of adiposity, insulin resistance, lipid profile and blood pressure and carotid-femoral pulse wave velocity (PWV), a validated non-invasive measure of arterial stiffness in a healthy cohort of school-aged twin children. PWV was performed on a population-based birth cohort of 147 twin pairs aged 7-11 years. Fasting blood samples, blood pressure and adiposity measures were collected concurrently. Mixed linear regression models were used to account for twin clustering, within- and between-twin pair associations. There were positive associations between both markers of higher adiposity, insulin resistance, elevated triglycerides and PWV, which remained significant after accounting for twin birth-set clustering. There was a positive association between both diastolic and mean arterial blood pressure and PWV in within-pair analysis in dizygotic, but not monozygotic twins, indicating genetic differences evident in dizygotic not monozygotic twins may affect these associations. Increased blood pressure, triglycerides and other metabolic markers are associated with increased PWV in school-aged twins. These results support both the genetic and environmental contribution to higher PWV, as a marker of arterial stiffness, and reiterate the importance of preventing metabolic syndrome from childhood.

Reliability, validity, and responsiveness of the Western Ontario and McMaster Universities osteoarthritis index for elderly patients with a femoral neck fracture

Background: The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) has been extensively evaluated in groups of patients with osteoarthritis, yet not in patients with a femoral neck fracture. This study aimed to determine the reliability, construct validity, and responsiveness of the WOMAC compared with the Short Form-12 (SF-12) and the EuroQol 5D (EQ-5D) questionnaires for the assessment of elderly patients with a femoral neck fracture.

Methods: Reliability was tested by assessing the Cronbach alpha. Construct validity was determined with the Pearson correlation coefficient. Change scores were calculated from ten weeks to twelve months of follow-up. Standardized response means and floor and ceiling effects were determined. Analyses were performed to compare the results for patients less than eighty years old with those for patients eighty years of age or older.

Results: The mean WOMAC total score was 89 points before the fracture in the younger patients and increased from 70 points at ten weeks to 81 points at two years postoperatively. In the older age group, these scores were 86, 75, and 78 points. The mean WOMAC pain scores before the fracture and at ten weeks and two years postoperatively were 92, 76, and 87 points, respectively, in the younger age group and 92, 84, and 93 points in the older age group. Function scores were 89, 68, and 79 points for the younger age group and 84, 71, and 73 points for the older age group. The Cronbach alpha for pain, stiffness, function, and the total scale ranged from 0.83 to 0.98 for the younger age group and from 0.79 to 0.97 for the older age group. Construct validity was good, with 82% and 79% of predefined hypotheses confirmed in the younger and older age groups, respectively. Responsiveness was moderate. No floor effects were found. Moderate to large ceiling effects were found for pain and stiffness scales at ten weeks and twelve months in younger patients (18% to 36%) and in the older age group (38% to 53%).

Conclusions: The WOMAC showed good reliability, construct validity, and responsiveness in both age groups of elderly patients with a femoral neck fracture who had been physically and mentally fit before the fracture. The instrument is suitable for use in future clinical studies in these populations.